Use the form to request an appointment.
We will call or email you to confirm.

Are you a new patient?

Yes

Full Name

Please include any middle names with your First Name

First Name

Last Name

Date of Birth

Home address

Please include city and area code

Phone number (Best number to be contacted on)

Phone number (Day time alternative) Optional

Email Address

Please use an email address you are happy for the All Women clinic to send correspondence to. This may include clinic letter's or results after your appointment .

Email Address (please re-enter)

Please re-enter your email address so we can help try and protect your privacy

GP Name

Who you are registered with

GP Practice

Are you a NZ citizen/Permanent resident?

If not a NZ Citizen/Permanent resident what type of Visa are you on?

Visa type and expiry date. Please note you may be required to provide a copy of your Visa for our records.

NHI Number

If known

Do you have health insurance?

If answer yes - please provide your insurance company and policy number below

Health Insurance Company

eg Southern Cross

Insurance Policy Number

If known

Who do you want to see?

If you're unsure who to see, then simply select GP with special interest in women's health

Reason for consultation

Please select what your main reason for yout visit with the doctor is. If unknown please click Unsure.

Comments or Questions

Consents

Please tick

Consent to use the email address provided to receive clinical information

Consent to share clinical visit records with enrolled practice

Consent to share health information with other health providers involved in my case

Consent to use of text messaging

Cancellation Policy: Please notify us at least 24 hours prior to your appointment to cancel or reschedule.

What to bring: Please remember to bring any medication you are taking to the appointment.